Ebola Virus Remains in Semen for Up to 9 Months

Action Points

New study results have confirmed that the Ebola virus can linger in semen for many months after patients recover from its life-threatening symptoms.

Note that the WHO has proposed that surveillance in endemic regions should remain heightened for 90 days after expiration of the 42-day period following cure of the last known patient, but this may not be adequate in light of the new study.

New study results have confirmed that the Ebola virus can linger in semen for many months after patients recover from its life-threatening symptoms.

Semen samples from several recovered Ebola patients in Sierra Leone tested positive for virus fragments up to 9 months after onset of the virus, according to a report published online in the New England Journal of Medicine on Wednesday.

"The main message from these papers is that long after the Ebola outbreaks end, the survivors and their partners and families will still face and be dealing with huge challenges, requiring strong national and international support for the next 6-12 months," World Health Organization (WHO) spokeswoman Margaret Harris told MedPage Today, adding that the affected countries are working to make sure survivors know the virus can linger and provide them with condoms and testing.

Gibrilla Fadlu Deen, MD, of Connaught Hospital in Freetown, Sierra Leone, and colleagues enrolled 100 male Ebola survivors over 18 years old who had been diagnosed with Ebola from 2 to 10 months prior to launch of the study, and 93 of them were included in the analysis.

The researchers found that 11 of the 43 those who were tested from 7 to 9 months after Ebola onset (26%) still had detectable levels of the virus in their semen.

"That's critical because the patient is otherwise well and is going to resume normal activities including sexual intimacies with partners," said William Schaffner, MD, chair of preventive medicine at Vanderbilt University, who was not involved in the study. "That can set up transmission of the virus and set up a new chain of transmissions. That's the time bomb that's ticking."

Deen and his team performed quantitative RT-PCR testing using Ebola-specific gene targets. They considered a semen specimen to be positive "if the VP40 and NP gene targets were both detected within 40 cycles of replication," according to the study.

Ebola survivors' semen also tested positive for Ebola between 2 and 3 months after onset (9 of 9 or 100%), and from 4 to 6 months after onset (26 of 40, or 65%). The one man who provided a semen sample to researchers 10 months after Ebola onset had "indeterminate" results.

Until men who have survived Ebola have had two negative semen tests, they should abstain from sexual activity or use condoms, the CDC said in a statement issued simultaneously with the NEJM publication; the WHO had issued similar advice earlier this year. Recommendations also call for those having contact with Ebola survivors' semen to wash their hands. Harris said everyone discharged from Ebola treatment units has been given a supply of as many as 90 condoms, but this number can vary from unit to unit.

Deen and his team noted that there have been fewer than 20 suspected cases of sexually transmitted Ebola reported.

As of Oct. 11, there have been 28,454 reported Ebola cases in Guinea, Liberia, and Sierra Leone, including 11,297 deaths, according to the WHO. The West African Ebola outbreak, which began in March 2014 is by far the largest Ebola outbreak in history.

"We had thought initially that once the patient had recovered, they had recovered and that was the end of it," said Schaffner, a former president of the National Foundation for Infectious Diseases.

Now public health workers are aware of post-Ebola symptoms, which include arthritis in the lower back and hips, central nervous system problems, and forgetfulness, Schaffner said. The virus can also survive in parts of the body that are protected from the immune system: the eye and the testes.

One of Schaffner's former students, Ian Crozier, MD, who contracted Ebola working as a WHO volunteer in Sierra Leone and was treated at Emory University in Atlanta, authored a study, and spoke to the New York Times earlier this year about how the virus survived in his eye and turned it from blue to green.

This week, a nurse in Great Britain who had survived Ebola was rehospitalized with symptoms attributed to post-Ebola syndrome and listed in critical condition, according to the BBC.

An accompanying editorial in the NEJM, by Armand Sprecher, MD, MPH, of Médecins sans Frontières (Doctors without Borders) in Brussels, noted that the confirmation of sexual transmission raises issues for nations and their public health systems, as well for individual patients.

Survivors and their sexual partners aren't the only ones who need to take precautions, he suggested. The WHO has proposed that surveillance in endemic regions should remain heightened for 90 days after expiration of the 42-day period following cure of the last known patient, but this may not be adequate in light of the new study, Sprecher rote.

He also urged that, as the potential for late transmission becomes known, governments and health systems must ensure that survivors don't become seen as "pariahs and threats," because that could undermine efforts to keep Ebola contained.

"If [survivors] find that being identified as a patient with [Ebola] has but two outcomes -- death in a frightening treatment unit or survival to return as a social outcast -- they have a considerable disincentive to be identified," Sprecher wrote. "This prospect may drive persons with new cases... into hiding and defeat the objective of the surveillance system."

Funded by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), the Sierra Leone Ministry of Health and Sanitation, and the Joint United Nations Program on HIV/AIDS (UNAIDS).

The views expressed in this article are those of the authors and do not necessarily represent the official positions of the World Health Organization (WHO) or the Centers for Disease Control and Prevention (CDC).

Reviewed by Robert Jasmer, MD Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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